Metamorphosis is Messy: a Plea for Medical Mercy

Recently, while reading the Sunday edition of the Salt Lake Tribune, I spotted an article about a medical malpractice suit against a local OB/GYN physician I’ve come to respect as a mentor. My first opportunity as a physician to act on my passion for transgender medicine came through the mentorship of this physician, who works in the community near my residency hospital. She routinely went out of her way to teach me and my fellow residents about obstetrics, gynecology and the art of transgender medicine without any monetary incentive. She has always modeled incredible sensitivity, expertise and fearless advocacy for her transgender patients. I thought the journalist did a decent job presenting both sides of the story, as far as possible; however, due to HIPPA (a law that protects patient health information from being disclosed) I know there is more to the story that she and her attorney are unable to share in her defense. While I do not know the patient in the case, I feel sympathy for the irreplaceable loss of their ovaries and reproductive potential. Nothing can restore what has been lost, and the best we can do is recognize, validate, and empathize, to the extent of our capacity, the pain of their loss. I must confess, seeing my mentor shamed in this very public controversy scares and saddens me, also, and part of me wonders whether I should turn back now from my passion for transgender medicine and not take the risk that someday I may find myself in the same situation. The trans community needs more, not fewer doctors. Without discounting Lesley’s pain and the loss they have suffered, let’s turn this into a constructive dialogue about how to meet the needs of the community and how to welcome and foster excellence among a new generation of trans-friendly providers.My first exposure to the unique and often tragic experience of transgender people in healthcare came in medical school as part of our reproductive health curriculum with a panel of brave transgender patients who told my class their stories and allowed us to ask very personal questions about their transitions so we could understand how to model the behaviors they appreciated and needed, and learn from the mistakes that other physicians had made. I was incredibly moved and felt passionately that, one day, I would make a place for the unique needs of these patients in my future practice.Several months ago, as part of a “community medicine” rotation, I had the opportunity to go explore the Utah Pride Center in downtown Salt Lake City. My guide alerted me to a list of LGBTQ-friendly medical providers that they keep as a resource for their patrons and I asked that my name be put on the list, without any expectation of what may follow. What followed were several new patients who sought me out in the following months, requesting medical assistance with their gender transitions. I was honored and humbled that, even after explaining that I am a resident still in training, they were willing to trust me and embark on this journey together.I was quickly conscious of the fact that I needed help from experts in the field to make sure I was providing compassionate, evidence-based care for my patients. This OB/GYN was naturally the first physician I reached out to, along with other providers from the University of Utah and one of my residency faculty members who was brave enough to learn about this new field of medicine and supervise me. These mentors provided me with indispensable resources, guidance and reassurance that I need not shy away or be afraid of pursuing my passion for transgender medicine, despite the unease and thinly-veiled hostility of many medical providers towards the needs of this marginalized population. I have learned through this outreach that the vast majority of medical providers here in Utah are unwilling to come anywhere near transgender medicine--due to ignorance about the science, fear of judgment and rejection from professional peers, religious and moral unease, philosophical conflict, and, most importantly, fear of litigation. This doctor has personally suffered incredible discrimination and ostracization by her OB/GYN peers for her commitment to serve the transgender community.The evidence is clear that people who suffer from gender dysphoria need to transition to the gender they identify with to preserve their mental and physical health, and yet there are very few medical providers, especially in politically conservative Utah, who are willing to meet these needs. It takes courage, passion and love to overcome these barriers as a physician and follow one’s conscience to do the right thing, no matter the social, financial and legal consequences. No physician I know has shown more courage, passion, and love for the LGBTQ community than my mentor.My fellow residents and I recently watched a TEDx talk together, in which an emergency room physician from Toronto does the unthinkable: he openly admits that he has made mistakes, which in some cases have led to terrible consequences for his patients, even death. He highlights that in medicine we have a culture of error-denial, strengthened by unrealistic public expectations, which insists that we must be perfect. In reality we, too, are human and work in systems that put too much emphasis on our individual abilities, acumen, diagnostic prowess and memory, and not enough on recognizing the limits of our cognitive abilities, and the systematic deprivation of our basic human needs (sleep, recovery, exercise, etc.). When mistakes occur, these systems are too quick to blame the “bad apples” and too slow to root out the systematic flaws that are truly the cause of these harms.When doctors make a mistake (and we ALL make mistakes), there are few legitimate avenues for us (not tied to repercussion and judgement) to talk with others so we can process it and help others learn and decrease the chance of the same mistake happening again. It goes unsaid, unexamined, and what remains is a culture of shame and social withdrawal from the community of our peers. It is easy to see how such a culture leads to vicious cycles of self-destructive thoughts and behaviors, and self-fulfilling prophecies that we are bad doctors, unworthy of our profession and the sacred trust of our patients. The truth is, if you eliminated all the doctors who make mistakes, including ones that hurt people, there would be none left.Maybe someday we will be replaced by super-intelligent diagnostic algorithms, pill dispensers and surgical robots, but until then we are the best generation of physicians and healers the world has yet seen. We will prevent, reverse and manage suffering with unprecedented efficiency, and aided by our tools we will detect, treat and cure more disease than ever before. Our profession will continue to expand into new realms, such as transgender medicine, life extension and enhancement. Despite the promises of modern medicine and our best efforts to live by and practice our credo of “First, Do No Harm,” our actions will have unintended consequences and, in increasingly rare cases, we will continue to cause pain, suffering, and death. Part of our job is to help our patients understand this conundrum through the process of informed consent, and to own our mistakes, apologize, learn and teach when we inevitably make them.Please try to see us as human, like you, and also as humanists who have dedicated our lives to doing the best we can to improve the human condition through medical science and compassion. The vast majority of us are not here for the money, but for the love of our art, a love which helps us overcome the fear of being sued if and when we fail. Please also recognize that medicine is risky business and actively engage with us in the process of informed consent for the screenings, tests, treatments and procedures we offer you. May we create a new model of shared medical decision making and risk taking as we approach the future of medicine, a future that includes morphological freedom and enhancement.